Laparoscopic-assisted colectomy in heart transplant recipients

Reports of laparoscopy in heart graft recipients are scarce and, to our knowledge, laparoscopic colectomy has not yet been reported in heart transplant patients. The magnitude and the tolerance of the hemodynamic changes induced by pneumoperitoneum are unknown in heart graft recipients, who have a denervated heart and are "preload-dependent". The authors report the clinical courses of 2 heart graft recipients who developed acute diverticulitis without perforation or peritonitis and who underwent laparoscopic-assisted colectomy without complications.

Proximal migration of vena caval filters: report of two cases with operative retrieval

Operative retrieval of two proximally migrated vena caval filters was performed in two patients, ages 42 and 45 years, respectively. In the first patient the filter was encrusted in the right ventricle, and in the second one the filter was found in the pulmonary artery. Both filters were retrieved under cardiopulmonary bypass via an incision in the right atrium and the pulmonary artery, respectively. These two observations underscore the risk of increased unwarranted indications and consequent higher complication rates of vena caval filters.

The impact of renal revascularisation on renal dysfunction

AIM

To determine the value of kidney revascularisation in patients with impaired renal function and correctable renal artery stenosis, the authors reviewed their surgical experience from 1978 to 1990.

PATIENTS AND METHODS

The study population included 23 patients with ischaemic nephropathy whose preoperative baseline creatinine level exceeded 20 mg/l (range 21-65 mg/l). This represents 20% of all patients operated on for renal artery disease during the same time interval. Preoperative risk profile, operative mortality, impact on hypertension and on renal function, and late survival were analysed. Renal function response to kidney revascularisation was defined as favourable (20% or more reduction of serum creatinine), moderate (stabilised serum creatinine values) or bad (further deterioration of renal function). All patients had atherosclerotic renal artery disease, involving a solitary kidney in five, both kidneys in 15 and one of the two kidneys in three patients. Hypertension was present in 74%. Revascularisation was unilateral in 10, bilateral in nine and associated with controlateral nephrectomy in four patients.

RESULTS

Four patients died postoperatively (three myocardial infarctions, one stroke). Four patients needed postoperative short-term dialysis. After operation, renal function improved in 13, stabilised in six and deteriorated in four patients (of whom two died). Follow-up among the survivors averaged 46 months. The mean serum creatinine value at last follow-up visit was 26.2 mg/l, a decrease of 7.7 mg/l compared to preoperative values (p < 0.05). Overall, 69% of azotemic patients submitted to renal revascularisation manifested a favourable response (45% improved and 24% stabilised). Three patients required long-term dialysis. The 5-year survival rate was 48%.

CONCLUSION

These data suggest that kidney revascularisation in patients with ischaemic nephropathy can restore or stabilise renal function, preventing evolution and end-stage renal disease and dialysis dependency.

Valve replacement for acute left heart endocarditis

Between January 1982 and June 1993, 66 patients (48 men and 18 women of mean (range) age 50 (21-77) years) underwent valve replacement for acute infective endocarditis. There were 45 aortic valve and 17 mitral valve infections. Four patients had bivalvular involvement. Fifty-three patients suffered from native valve endocarditis, with underlying valvular lesions documented for 31 patients. Staphylococci and Streptococci spp. were responsible for 68% of infection, and 20% of blood and valve cultures were negative. Refractory congestive heart failure was the leading surgical indication in 86% of patients. The mean follow-up period was 44 months. The perioperative mortality rate was 6%. Actuarial survival rates were 88.5% at 1 year and 83% at 3 years. No early recurrence of infection was noted. Six patients (9%) needed reoperation. Satisfactory results confirm that early surgical management should be considered in patients with complicated infective endocarditis.

Diaspirin crosslinked hemoglobin (DCLHb): absence of increased free radical generation following administration in a rabbit model of renal ischemia and reperfusion

In control rabbits, a renal ischemia of 60 min followed by 10 min of reperfusion resulted in an enhanced free radical production in cortical tissue, as assessed by a significant decrease of free glutathione (42%), protein-bound GSH (17%), and vitamin E (49%). In contrast, catalase or glutathione peroxidase activities were not affected by these experimental conditions. Free radical production in this model was also measured directly using electron spin resonance (ESR) spectroscopy associated with a PBN (alpha-phenyl N-tert-butyl-nitrone) spin trap agent in the venous blood arising from the ischemic kidney. The signal consisted of a triplet of doublets. In contrast, no signal could be detected in control blood samples taken prior to inducing ischemia. The burst of free radical production occurred in the early phase after restoration of flow in the kidneys rendered ischemic, as evidenced by a signal of weak intensity which generally appeared within the third minute after reperfusion and progressively increased to form a well-defined asymmetric signal following 10 min of reperfusion. The precise nature of free radicals trapped by the PBN agent remains, however, to be elucidated, but analysis of the coupling constants (aN = 14.5-15 G; a beta H = 2.5-3 G) and asymmetry of the central doublets suggests that the ESR signal may arise from a nitorxy-radical adduct resulting from the spin trapping by PBN of both oxygen- or carbon-centered radicals of lipid origin. As evidenced by both direct and indirect measurements, exchange of rabbit blood immediately after inducing renal ischemia with 30 ml/kg of Diaspirin Crosslinked Hemoglobin (7.5 g/dl in lactated electrolyte) or human serum albumin (7.5 g/dl in lactated electrolyte) did not exacerbate free radical production mediated by an ischemia reperfusion phenomenon, a typical situation found in a resuscitation setting.

Successful abdominal aortic aneurysm resection in long-term survivors of cardiac transplantation

With the improvement of survival rates following cardiac transplantation, the probability of recipients developing extracardiac disease is increased. Three cases are reported of abdominal aortic aneurysm successfully operated on in cardiac allograft recipients 1 to 4 years after transplantation. Indications for transplantation were valvular, idiopathic and ischaemic cardiomyopathy. Post-transplant hypertension and hyperlipidaemia may have played a role in the rapid growth of the aneurysms. Cardiac function and the incidence of graft atherosclerosis were assessed before surgery by coronary angiography. All three patients were discharged from hospital. Abdominal aortic aneurysm resection may be a safe procedure in cardiac transplant patients. In view of the rapid increase in the size of the aneurysms in transplanted patients, careful screening should be performed during follow-up.

Attitude of a young surgeon toward experimental surgery. Roles and limits of experimental surgery

At the moment, the place of experimental surgery within the clinical surgical cores is questioned. However, its role in the progresses of surgical practice and training of surgeons is undisputable. It is through research that surgeons can keep some critical mind, essential in their daily activities. However, too often actually, the surgeons abandon research. Two essential reasons explain the phenomenon: on the one hand, the weight of the clinical tasks and on the other hand the complexity of research founded on more and more specialized basic notions. In fact, the part of a surgical investigator must be to form a link between basic research and clinical activities. As such, work in collaboration with motivated basic investigators is cardinal. Also, the success of research depends upon the will of the departments to maintain a research activity, but it meets often with the difficulty in obtaining sufficient research credits. Finally, research can play an essential part in the education of the trainees and partly fill some gaps in their clinical training.

Pacemaker implantation for early sinus node dysfunction after orthotopic heart transplantation

Among 60 patients who received OHT at our institution between November 1986 and January 1990, 4 actually needed implantation of a permanent pacemaker. Three patients with symptomatic early sinus node dysfunction were identified and were satisfactorily paced on the VVIR mode. All three showed sinus recovery within three months following implantation and had their pacemaker switched from the VVIR mode to a simple ventricular demand pacing. Interestingly, administration of beta-blocking drugs quickly reinstituted pace dependence. The patients' outcome is excellent (18 to 48 months follow-up). No difference with the global cohort of our OHT recipients was noticed, apart from an apparent high incidence of infections (3/3) with (2/3) CMV and severe rejection (3/3) during the first month postoperatively. This data suggests that sinus dysfunction may be the result of a multifactorial (rejection, CMV, ...) injury to the conduction system, and is only clinically relevant beyond a threshold level. Denervation hypersensitivity, together with correction of these factors, may account for the restoration of a sufficient reserve of conduction system, and therefore appropriate sinus node function in basal conditions.

Isolated atherosclerotic aneurysms of the iliac arteries

Atherosclerotic aneurysms limited to the iliac arteries are rare and entail a high risk of rupture. To evaluate the efficacy of prophylactic surgery, we retrospectively studied 15 patients (13 men and two women; mean age 69 years) treated for isolated iliac aneurysms in the Department of Cardiovascular Surgery at the University Hospital of Liège over a period of 18 years. They had a total of 25 aneurysms (20 common iliac and five internal iliac). Six patients were treated electively and nine on an emergency basis for rupture. Five of the emergency patients (33%) died in the early postoperative period (< 30 days); in each case the aneurysm had ruptured and an emergency operation was performed (55.5% mortality in the ruptured iliac aneurysm group). On the other hand, all patients treated electively survived. Our study is comparable to other recent series in the literature, which also reported a high incidence of rupture and death in emergency operations. Prophylactic elective surgery is recommended for iliac aneurysms.

Mechanical flow obstruction after heart transplantation diagnosed by TEE

We report a case of mechanical flow obstruction after heart transplantation caused by a prominent left atrium suture with a "pursestring" effect. The diagnosis was achieved by transesophageal echocardiography. The mean transstenotic gradient was measured at 13 mm Hg. Because of the profound hemodynamic and multisystemic failure, no surgical correction was attempted. The postmortem examination confirmed the stenosis at the level of the left atrium.

Direct evidence of free radical production after ischaemia and reperfusion and protective effect of desferrioxamine: ESR and vitamin E studies

After surgical renal revascularisation, warm renal ischaemia due to renal artery cross-clamping contributes to postoperative renal dysfunction. After reperfusion, free radicals are thought to be a significant cause of injury. Nevertheless, indisputable proof of free radical production is scarce, partly because of their transient nature. In this study, electron paramagnetic resonance and vitamin E levels were used to demonstrate the free radical production after renal ischaemia and reperfusion. Rabbit kidneys were submitted either to 15 or 60 minutes of ischaemia followed by reperfusion. A spin trap agent (alpha-phenyl-N-tert-butyl nitrone (PBN), 20mg/ml, 1 ml/min) was infused during reperfusion directly into the left renal artery via an aortic catheter before declamping. Blood samples were selectively drawn from the left renal vein for ESR analysis (Varian spectrometer E109) of lipidic residues extracted from blood samples. The vitamin E content of the left renal cortex was determined by HPLC procedure. The right renal cortex was used as a control for the vitamin E values. In the venous effluent, ESR analysis revealed the formation of a spectrum consisting of a triplet of asymmetric doublets. This signal resulted from the spin trapping by PBN of a mixture of both oxygen- and carbon- centred lipidic radicals. The amplitude of the signal which is proportional to the amount of free radicals was significantly higher after 60 minutes ischaemia than after 15 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

Preservation of cortical microcirculation after kidney ischemia-reperfusion: value of an iron chelator

Treatment of suprarenal aneurysms and renal artery reconstructions are both responsible for normothermic ischemia of the kidney (during clamping) followed by reperfusion (declamping). During reflow through an organ undergoing ischemia the production of free radicals can be associated with cell injury and a no-reflow phenomenon characterized by perfusion defects after a period of transient hyperemia. The objectives of this study were to demonstrate the existence of this phenomenon in the kidney undergoing ischemia followed by reperfusion and to test the potential protection afforded by an iron chelator (desferrioxamine) since free radical reactions are catalyzed by iron. Adult New Zealand white rabbits were divided into the following three groups: group A, 15 minutes of ischemia plus 10 minutes of reperfusion; group B, 60 minutes of ischemia plus 10 minutes of reperfusion; and group C, 60 minutes of ischemia plus 10 minutes of reperfusion combined with infusion of desferrioxamine (50 mg/kg). Cortical microcirculation in the kidney was measured by laser Doppler flowmeter before ischemia and 1, 5, and 10 minutes after reperfusion. Vitamin E content was determined in the cortex of the left kidney after 10 minutes of reperfusion and compared with that of the right (control) kidney. After 1 minute of reperfusion the cortical microcirculatory flow was significantly increased in all three groups (reactive hyperemia). In groups A and C blood flow returned to preclamping values after 10 minutes of reperfusion; however, blood flow in group B remained significantly reduced (29.2% +/- 10.5%) after 5 minutes of reperfusion with a further reduction to 48.5% +/- 5.7% after 10 minutes. These findings were correlated with the dosage of vitamin E since the vitamin E content was greatly reduced by 46.7% +/- 7.8% in group B but did not change significantly in groups A and C. This study shows that 60 minutes of normothermic ischemia is followed by a significant reduction in cortical microcirculatory flow (no-reflow phenomenon). Infusion of an iron chelator (desferrioxamine), however, which decreases the intensity of lipid peroxidation induced by the free radicals, preserves the microcirculatory flow.

The effect of technical conditions and storage medium composition on the phosphomonoesters to inorganic phosphate ratio determined by 31P nuclear magnetic resonance spectroscopy in rabbit kidney

Using 31P nuclear magnetic resonance spectroscopy, we compared the state of the high-energy phosphates in rabbit kidneys stored at 4 degrees C for 24 hr with 3 different solutions: Ringer (Rg), University of Wisconsin (UW), and Euro-Collins (EC) solutions. We found the highest phosphomonoester/inorganic phosphate (MP:Pi) ratio in the group of kidneys stored in the Rg solution (Rg, 0.93 +/- 0.04; UW, 0.36 +/- 0.02; EC, 0.28 +/- 0.02). This medium has been demonstrated in previous physiological studies to give poor results in terms of organ preservation compared to the solutions that mimic the "intracellular" fluid, such as the EC and UW solutions. Because the commonly used cold storage solutions contain phosphates, which superimpose on the intracellular Pi and, thus, can distort the results, we attempted to eliminate the contaminating solution around the kidney and in the vasculature by flushing the kidney with a phosphate-free solution (Rg). The MP:Pi ratio increased in the UW and EC groups (UW, 0.82 +/- 0.04; EC, 0.64 +/- 0.04) in identical proportion in the 2 groups. It remained highest in the Rg group (1.02 +/- 0.03). Comparisons of data before and after flush showed that external phosphate contamination was not predominant. There was no equilibrium in phosphate distribution between intra- and extracellular spaces at 24 hr of storage. We conclude that the validity of the MP:Pi ratio, as a viability index of renal transplant, might have to be restricted to comparisons of kidneys preserved in the same storage conditions. Therefore, it would be necessary to establish normal and pathological values of this ratio for each cold storage solution.

Evidence for free radical formation during human kidney transplantation

Fourteen patients undergoing kidney transplantation were studied for evidence of the production of free radicals as assessed by the measurement of vitamin E (an index of lipid peroxidation) and of myeloperoxidase (a marker of neutrophil activation) in the systemic blood. Early (2 min) and late revascularization (30 min) of the kidney were respectively associated with a significant decrease of 35.5 and 40% of the initial level of plasma vitamin E. This consumption paralleled to the decrease of the vitamin E/total lipids ratio, a better indicator of vitamin E status. Heparin administration preceding renal artery clamping resulted in a twofold significant increase of baseline plasma myeloperoxidase (MPO) level (523 +/- 214 ng/ml). At kidney reperfusion, MPO concentration rose again and reached a maximum value of 1,653 +/- 882 ng/ml, indicating the presence of considerable neutrophil activation. A return to the baseline value was observed after 30 min of reperfusion. A short discussion about the possible origin of this MPO increase is given. Taken together, these data strongly suggest that free radical production, leading to lipid peroxidation phenomena, can occur within the early phase of kidney revascularization. Preliminary data using electron spin resonance with the spin-trapping technique strengthen this hypothesis.

In vivo free radical production after cross-clamping and reperfusion of the renal artery in the rabbit

Postischaemic reperfusion injury is often attributed to the generation of oxygenated free radicals which may subsequently promote lipid peroxidation in cell membranes. Electron paramagnetic resonance spectroscopy in association with the spin trap molecule alpha-phenyl-N-tert-butyl-nitrone allowed direct confirmation of lipid free radical production after renal ischaemia-reperfusion in an in vivo rabbit model. A 60-min period of ischaemia followed by reperfusion caused free radical production twofold greater than after 15 min of ischaemia. Glutathione and alpha-tocopherol have been measured in renal tissue, as indirect markers of lipid peroxidation. After 15 min of ischaemia followed by 10 min of reperfusion, the mean(s.e.m.) glutathione content of the ischaemic kidney was slightly but significantly reduced by 11.9(2.5)% (P < 0.003). The content of alpha-tocopherol was unchanged. However, 10 min of reperfusion following 60 min of ischaemia led to significant decrease in mean(s.e.m.) content of both glutathione (30.4(3.7)%) (2.23(0.2) versus 3.14(0.18) mumol/g wet tissue, P < 0.001) and alpha-tocopherol (46.1(7.8)%) (0.57(0.10) versus 1.09(0.14) micrograms/g wet tissue, P < 0.001) when compared to the control kidney. Under these experimental conditions, desferrioxamine (15 mg/kg administered intravenously before inducing ischaemia), a drug known to limit free radical production, significantly limited the decrease of alpha-tocopherol to 20.8(6.4)% (0.83(0.08) versus 1.05(0.04) micrograms/g wet tissue, P < 0.05), but did not prevent glutathione consumption in the reperfused kidney.

Misdiagnosed malignancy in transplanted organs

The case reports of three patients who received cancer-bearing organs at this institution are presented. A fourth recipient, who was to be transplanted with a cancerous kidney, was spared this disastrous complication. The relevant data regarding the donors is also alluded to, with special reference to the type and site of the primary malignancy. Following these case reports, the implications of these issues, their possible prevention, and further management are discussed.

Misdiagnosed malignancy in transplanted organs

The case reports of three patients who received cancer-bearing organs at this institution are presented. A fourth recipient, who was to be transplanted with a cancerous kidney, was spared this disastrous complication. The relevant data regarding the donors is also alluded to, with special reference to the type and site of the primary malignancy. Following these case reports, the implications of these issues, their possible prevention, and further management are discussed.

Association of aortic stenosis and gastrointestinal bleeding (Heyde's syndrome). Report of two cases

The association between aortic stenosis and digestive angiodysplasia has been described for the first time by Heyde in 1958. This entity is thus known as Heyde's syndrome. In many instances, the recurrent small intestinal bleeding originating from angiodysplasia stopped after aortic valve replacement. We report two cases of patients presenting with a recurrent small intestinal bleeding originating from digestive angiodysplasia and suffering from aortic stenosis. Diagnosis of both pathologies is well documented in both cases. The replacement of the aortic valve by a biologic prosthesis stopped the bleeding. Prior to aortic valve replacement, the two patients suffered severe recurrent blood loss from intestinal angiodysplasia. The treatment of aortic stenosis greatly favored both cardiac and general status. We recommend aortic valve replacement with a biologic prosthesis prior to intestinal resection in patients presenting with Heyde's syndrome. We stress on the fact that anticoagulants must be stopped in order to minimize the risk of further bleeding.

Aneurysm of the ascending aorta after cardiac transplantation

We report the case of a 57-year-old female cardiac transplant patient in whom an aneurysm of the recipient side of the ascending aorta developed 1 year after transplantation. Although a mycotic origin was the likely cause, histologic examination diagnosed an atherosclerotic aneurysm.

[Oxygen metabolism and toxicity in the phenomenon of ischemia-reperfusion]

One of the major cause of human disease results from the compromise of blood flow and oxygen delivery to tissues. Ischemia phenomenon is defined as blood flow that is inadequate to maintain normal tissue function. Prolonged ischemia ultimately results in irreversible changes in cell metabolism and cell death. Historically, it was felt that if ischemia results in altered cell function and injury, then reoxygenation or reperfusion leading to a restoration of a normal blood flow was expected to have a beneficial effect and promote salvage of tissue depending on the extent of ischemia. Recent studies have, however, revealed that reoxygenation leads to an oxygen metabolism resulting in the generation of active and toxic oxygen intermediates (free radicals) which play an important role in the pathophysiology of reperfusion injury.

Brachiocephalic arterial reconstruction

From 1980 to 1990, 18 patients underwent trans-sternal repair for occlusive disease of the brachiocephalic artery. The mean age was 57 years (43-72). Most of the patients were women (n = 10). All but two patients had one or more symptoms related to the stenosis of the brachiocephalic trunk: right-sided upper limb ischemia (n = 7), transient ischemic attacks (n = 8), vertebrobasilar insufficiency (n = 6), left sided minor stroke (n = 1). Only two patients were asymptomatic before operation. Angiography revealed a tight stenosis (n = 14) or an occlusion (n = 3); in one patient it concerned an ulcerated non-stenotic plaque of the brachiocephalic artery. Eleven patients had coexistent involvement of other supraaortic vessels. Angiographically, clinically and intraoperatively, there was evidence of Takayasu arteritis in three female patients. All patients had direct repair by trans-sternal approach. Six patients with short lesions had thromboendarterectomy with patch angioplasty of the innominate artery. In eleven cases, aorto-brachiocephalic bypass grafting was performed. In one patient, aortic calcification precluded proximal anastomosis, and a carotid-to-carotid bypass was done. In five patients, simultaneous revascularization of subclavian (n = 3), left common carotid (n = 2) or internal carotid artery (n = 2) completed the procedure. In one patient, concomitant coronary revascularization was done. There was no operative mortality. Postoperative morbidity was limited to pulmonary infection (n = 2), transient neurologic deficit (n = 1) and renal insufficiency (n = 1). All patients had relief of symptoms. Duplex echo scan confirmed patency of all reconstructions at a mean follow-up of 46 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Right aortic arch with aberrant left subclavian artery. Report of two cases

Two cases of adult asymptomatic right aortic arch with an aberrant subclavian artery are reported. They were discovered at time of coronary surgery. Preoperative coronary arteriography failed to demonstrate the anomalies. In one case, the right arch was suspected on chest x-ray and preoperative barium oesophagography. In one case, the proximal suture of one saphenous bypass graft was performed on the left common carotid artery. Right aortic arch is a malformation rarely discovered in adults. It generally produces no symptoms when not associated with cardiac disease.

Axillounifemoral and axillobifemoral bypasses. Retrospective study of 85 cases

From 1983 to 1990, 65 axillobifemoral and 20 axillofemoral bypasses have been performed in 85 patients (77 men and 8 women), with a mean age of 69 +/- 9 years. Indications for surgery were: severe aortoiliac occlusive disease (87%), sepsis of previous aortoiliac prosthesis, abdominal aorta aneurysm. Anatomic bypass was precluded for general (81%) or local (19%) conditions. In the last group, 9 patients have had previous laparotomy. Four patients presented with aortoenteric fistulas. Eighteen patients were operated on in emergency. The operative mortality was 12%, with 50% cardiac related deaths. Early primary patency was 98%. Early secondary patency was 100%. The mean follow-up is 28 +/- 15 months. The 3 years survival is 77%. The cumulative patency rates at 1 and 3 years are 89% and 76% respectively. Although axillobifemoral bypasses achieve poor long-term results when compared with aortoiliac bypasses, they can be considered in high risk patients. In this group of patients, the cumulative patency rate and the survival curves tend to be parallel.

Truncal vagotomy and pyloroplasty combined with valvular replacement in patients with ulcer disease

In 1988, 5 patients (3 men and 2 women) with ulcer disease (mean age 56 +/- 8 years) underwent valvular replacement for aortic (No. = 4) or mitral disease (No. = 1). All patients had had gastroduodenal ulcers. Preoperative gastroscopy demonstrated active ulcers (No. = 4) and a healed pyloric ulcer with pyloric stenosis (No. = 1). Despite the presence of ulcers, a non-biologic prosthesis was preferred in each patient because of their young age (No. = 3), chronic atrial fibrillation requiring anticoagulant therapy (No. = 1), and refusal of the eventuality of subsequent reoperation (No. = 1). In each patient, a truncal vagotomy with pyloroplasty was performed simultaneously with the valvular procedures by the same incision. The postoperative courses were uneventful. With a mean follow-up of 15 +/- 3 months, no gastrointestinal bleeding was observed during anticoagulant therapy. With anticoagulant drugs, bleeding may occur with a frequency of 4% per patient treatment-year, half of which are gastrointestinal in origin. Nevertheless, in selected patients with gastroduodenal ulcers, performing a vagotomy-pyloroplasty simultaneously with valvular replacement allows implantation of a non-biologic prosthesis, with greater durability than bioprosthesis.

Surgical management of left atrial myxoma

Although rare, left atrial myxoma is an entity from anatomopathological and clinical aspects. Seven cases of left atrial myxoma operated on the last ten years were reviewed. We also report a rare presentation of right atrial myxoma, where the tumor was responsible of a dramatic hemodynamic shock due to right ventricular inflow obstruction. Six patients were female, with a mean age of 53 years. All but one consulted for exertional dyspnea of recent onset. Two patients with left atrial myxoma and the patient with right atrial myxoma had experienced embolism. Five patients had systemic symptoms. Echocardiography was the most performant diagnostic procedure. All but the patient with right atrial myxoma were operated by the left atrial access. The mitral valve was replaced in two patients. The histological aspect of this benign tumor is illustrated but the lack of frank border between the tumor and the myocardium is emphasized. We conclude that surgical management is primordial. We give anatomopathological rationale for resection of implantation pedicle. The operative mortality was nul in this series of 8 patients; major improvement of cardiac status was constant. No recurrence has occurred during the follow-up period.

Cardiac transplantation in patients older than 55 years

From 1985 to 1990, 27 patients older than 55 years (extremes 55-65 years; 21 men and 6 women) received a cardiac transplant. The cause of cardiopathy was ischemic in 70%. Postoperative immunosuppressive therapy consisted of Cyclosporin A, steroids, azathioprine and antilymphocytic serum. Rejection episodes were monitored by endomyocardial biopsies and treated by pulses of steroids or monoclonal antibodies (OKT3). The operative mortality is 7.4% (n = 2). The one and two year survivals are 71% and 62% respectively. The incidence of infection and/or rejection were 0.71 +/- 0.4 and 1.4 +/- 0.7 episodes/patient year. Age beyond 55 years does not contraindicate heart transplantation. This change in recipient selection policy should lead to parallel changes in donor selection criteria.

Carotid-subclavian bypass with or without carotid endarterectomy

From 1981 to 1987, 29 patients (14 women and 15 men, with a mean age of 56 +/- 15 years) underwent a carotid-subclavian bypass for occlusive lesion of the subclavian artery (or of the left common carotid artery). The symptomatology included vertebrobasilar insufficiency, arm ischemic symptoms, or combination of both symptoms. Twelve patients (42%) have had a previous transient ischemic attack, or a cerebrovascular accident. There were 22 stenoses or occlusions of the left subclavian artery, and 6 of the right subclavian artery. On arteriography, 9 patients had significant associated lesions on the internal carotid artery, either homolateral (n = 7), or heterolateral, or bilateral. Carotid to subclavian bypasses were performed either with autogenous saphenous vein (n = 15), or with prosthetic graft (n = 14). In 5 cases, a carotid endarterectomy was done simultaneously to the bypass. Operative mortality was 3.4% (1/29). Early patency (less than 1 month) was 97% and late patency 89%, with a mean follow-up of 40 +/- 24 months. The patency rates were not significantly different whether a prosthesis or a vein was used for the bypass. All patients were improved and complete relief of symptoms was achieved in 92%. No patient experienced symptoms of carotid steal after the bypass. We concluded that carotid-subclavian bypass is a safe and efficient method for revascularization of the subclavian artery of of the left common carotid artery in selected cases.

Valvular and coronary surgery in renal transplant patients

The Authors report aortic valvular replacement (AVR) and coronary artery bypass graft surgery (CABG) successfully performed in two renal transplant patients. The postoperative blood urea and creatinine levels were comparable to the preoperative values. The first patient underwent isolated AVR. The second patient had an initial AVR combined with CABG followed two years later by a further AVR for prosthetic dysfunction. For many reasons, coronary artery (CAD) and valvular diseases are not uncommon in renal transplant patients. Cardiac surgery is feasible without impairment of the renal function provided some precautions are taken, ie good mean perfusion pressure during cardiopulmonary bypass (CPB), adequate volume replacement, and selected use of mannitol and dopamine.

[Simultaneous coronary and carotid surgery: apropos of 73 cases]

A series of 73 simultaneous carotid and coronary revascularizations (Group I) is presented (January 1980-December 1988). Age, sex, risk factors, severity of angina, coronarography, neurological symptoms, angiographic carotid lesions and operative outcome of these 73 patients are compared with the aspects of 3544 coronary bypass patients (Group II) and 1001 carotid endarterectomized patients (Group III) during the same period. The angina in Group I is more severe, with 22% belonging to NYHA class IV and 26% having a stenosis of the left main coronary artery, vs 14% and 13% in Group II. Seventy percent of the carotid lesions in Group I are asymptomatic vs 33% in Group III. Group I patients had more problems in the perioperative period, with 16.4% needing prolonged high-doses analeptics and 5.4% intraaortic counterpulsation balloon. Operative mortality is higher (7%) in Group I compared with Group II (2.3%) and Group III (1.7%). These results permit to define a population of polyvascular patients with concomitant coronary and carotid disease, characterized by a more diffuse atherosclerosis and a higher operative risk. Operative morbidity and mortality after combined myocardial and cerebral revascularization remains nevertheless inferior to the cumulated surgical risk of the sequential procedures (74 patients with coexistant coronary and carotid lesions operated in two sessions before 1986).

Combined one stage cardiac and pulmonary surgery by median sternotomy

From 1985 to 1989, 6 patients underwent a pulmonary surgical procedure simultaneously with a cardiac operation. All patients were male with a mean age of 60 +/- 8 years. The cardiac procedures included: 1 aortic and 1 mitral valve replacement, 3 coronary artery bypass grafts and 1 closure of an atrial septal defect. Four patients had primary pulmonary nodules: 2 bronchogenic carcinomas and 2 benign hamartomas. They presented with cardiac symptoms, and lung nodules were incidentally found on preoperative Chest X-Rays. The 2 last patients had pulmonary metastases of colonic neoplasms previously resected, respectively 3 and 6 years before. After completion of the cardiac procedures, during the rewarming of the patient, the pulmonary resection was performed on a deflated lung, via the median sternotomy. Pulmonary procedures included: right upper segmentectomy (n = 1), left pneumonectomy (n = 1), left interior lobectomy (n = 1), right middle lobectomy (n = 1), left upper wedge resection (n = 1), and right upper lobe wedge resection (n = 1). All patients were extubated on day one. One patient died from rythm disturbances on day 13. All other patients are alive with a mean survival of 30 months. The authors conclude that combined surgery is feasible in selected cases. Sternal approach is not a limitation to pulmonary resection.

Cardiac transplantation beyond 55 years of age

Between January 1985 and December 1988, 20 patients over the age of 55 years (extremes 56-63 years; 15 men and 5 women) underwent cardiac transplantation. The cause of cardiopathy was ischemic in 70% of the cases. The immunosuppressive regimen consisted of cyclosporin A, corticoids, and azathioprine. Rejection episodes were monitored by endomyocardial biopsies and treated by pulses of corticoids or monoclonal antibodies (OKT3). The operative mortality was 10% (n = 2). The 1-year survival rate was 70%. The 1-year incidence of infection and/or rejection episodes was 1 and 1.53 episodes/patient, respectively. One patient was successfully retransplanted after 9 months because of intractable rejection. Age beyond 55 years is no longer a contraindication to cardiac transplantation. This change in recipient selection policy should lead to parallel changes in donor selection criteria.

Renal autotransplantation: a kidney-saving procedure

The authors report their recent experience with renal autotransplantation (3 cases). In one case it concerned a complex aneurysm of the renal artery involving secondary arterial renal branches, and associated with hydronephrosis (case 1); another patient presented a high ureteral injury unsuccessfully repaired by previous surgery (case 2), and the third patient had diffuse fibrodysplasia of intrahilar arterial branches (case 3). The procedures were technically successful and gave good functional results. They describe the technique of kidney refrigeration, extracorporeal vessel repair and ureteral preservation or reimplantation. Indications and technical advantages of this organ-saving reconstructive approach are discussed.

[Mitral valve replacement in post-infarction rupture of the papillary muscle. Apropos of 13 cases surgically treated during the acute phase of infarction]

Between 1983 and 1988, thirteen patients (12 men and 1 women, average age 63 years) were operated in the acute phase of myocardial infarction for papillary muscle rupture (PMR). The rupture involved the posterior papillary muscle in 12 cases. The average left ventricular ejection fraction was 47 +/- 9 per cent (range 34 to 63%). Pulmonary capillary pressures ranged from 76 to 41 mmHg (average 35 mmHg). Eleven patients presented with acute pulmonary oedema and 7 had cardiogenic shock. Coronary arteriography showed triple vessel disease in 3 cases, double vessel disease in 7 cases and single vessel disease in 3 cases. Surgery was carried out on average 2.7 days after the rupture and 10 days after the initial infarct. In addition to mitral valve replacement (N = 13), 11 patients underwent a myocardial revascularisation procedure. The operative mortality was 15 per cent (N = 2). Papillary muscle rupture in the acute phase of myocardial infarction causes cardiac failure which is related more to the mechanical abnormality than to an alteration of left ventricular function. Considering the operative mortality and the natural history of PMR treated medically, the authors recommend early surgery as the only management which can improve the precarious haemodynamic status of patients with this complication.